Basic Information
| Provider Information | |||||||||
| NPI: | 1023447026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOGAN | ||||||||
| FirstName: | THERESA | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18109 PRINCE PHILIP DR STE 155 | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012603280 | ||||||||
| FaxNumber: | 3012603279 | ||||||||
| Practice Location | |||||||||
| Address1: | 18109 PRINCE PHILIP DR STE 155 | ||||||||
| Address2: | |||||||||
| City: | OLNEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208321591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012603280 | ||||||||
| FaxNumber: | 3012603279 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2013 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A3033 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.